Inspection on 04/05/06 for 52 Porthcawl Green

This inspection was carried out on 4th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

52 Porthcawl Green 25/03/09

52 Porthcawl Green 08/01/09

52 Porthcawl Green 22/10/08

52 Porthcawl Green 31/10/07

52 Porthcawl Green 28/12/06

52 Porthcawl Green 15/11/05

52 Porthcawl Green 05/07/05

52 Porthcawl Green 13/07/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Porthcawl Green (52) 52 Porthcawl Green Tattenhoe Milton Keynes Buckinghamshire MK4 3AL Lead Inspector Gill Gentles Unannounced Inspection 4th May 2006 08:30 Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Porthcawl Green (52) Address 52 Porthcawl Green Tattenhoe Milton Keynes Buckinghamshire MK4 3AL 01908 506865 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Disabilities Trust Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Porthcawl Green is a home in the community managed by the Disability Trust. The home accommodates three males with Autistic Spectrum Disorders. The house is situated on an estate in Milton Keynes, close to the Westcroft centre where there are several shops and supermarkets. Local transport networks gives access to central Milton Keynes and Bletcheley. There is a main line train station in the city giving access to London and the North. The home has three bedrooms, one en-suite, a sleeping in room, a visitor’s room and a bathroom on the first floor. On the ground floor there is a large lounge, dining room, office, laundry and kitchen. There is a small garden, mainly laid to lawn with pretty floral boarders. There is ample communal parking at the front of the home for staff cars and visitors. At the time of the inspection the base fees were £1340.00 plus additional one to one time priced separately. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Gill Gentles and Mrs Nicky Cahill carried out this inspection unannounced during a period of approximately 7.5 hours. The inspection focused on service user outcomes by looking at records pertinent to Service Users and talking with service users to ascertain their personal views on the care being received. 2 relative comment cards were returned to the Commission for Social Care Inspection prior to the inspection-taking place. Staff were informally interviewed during the inspection day and also completed questionnaires. The evidence seen and comments received indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its statement of purpose. What the service does well: What has improved since the last inspection? What they could do better: Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 6 Care plans do not reflect service users choices, lifestyles, needs and aspirations therefore the service is failing to meet service users current needs. Consultation with service users was limited with no feedback being evident. Risk assessments were not dated potentially placing service users at risk. Activity planners are available for each service user, however, these fail to incorporate service users choice and allow personal flexibility. Service users are encouraged to select a meal each per weekly menu, limiting control and choice about their lives. A few discrepancies in medication were identified potentially placing service users at risk. The organisation ensures that the appropriate policies, procedures and training are available to staff to ensure service users are protected from harm, however, concerns need to be taken more seriously to ensure service users believe that their issues are being taken seriously. Documentary evidence shows a low percentage of staff are adequately and appropriately trained in NVQ’s potentially failing to ensure residents are cared for by competent and qualified staff. The home is failing to maintain its aims and objectives in the absence of the manager therefore failing to offer service users clear leadership and direction. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome are good: This judgement has been made using available evidence including a visit to this service. Prospective service users are given information that will help them make an informed choice about where to live. The organisation has an appropriate assessment policy and procedure to ensure that all prospective service users are assessed for suitability and compatibility. EVIDENCE: The home has the appropriate Statement of Purpose and Service Users Guide in place to ensure that prospective service users are given a clear picture of the home and the facilities it offers. However, existing service users did not appear to have their own copies as they were held in their individual personal files in the office. The home has not had any vacancies for a number of years so no new assessments had been carried out. The Disabilities trust has an organisational policy, which is then tailored to each service. A copy of the ”Autism Services Admission Criteria” procedure and protocol was in place. It was confirmed by the service manager that this policy would be followed in the event of a referral being received. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service.” Care plans do not reflect service users choices, lifestyles, needs and aspirations therefore the service is failing to meet service users current needs. Consultation with service users was limited with no feedback being evident. Risk assessments were not dated potentially placing service users at risk. EVIDENCE: Each service user has a personal file, care plan file, activities file and daily records file maintained in the main office. A requirement from the previous inspection “to ensure that the plans incorporate residents needs, wishes and aspirations for the future” was issued. However, care plans were found not to reflect the current, and ongoing needs of service users e.g. one service user plans to move on and their were no transition plans developed. Another service user did have a few goals identified however these were dated September 03 and apparently not reviewed. Personal plans were found to be sketchy with most of the information relating to service users having not being completed. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 10 Care Plans were written in the third person and not the first. There was no evidence that service users were involved in planning their care. One service user when asked if the Care Plan could be viewed asked, “What is a care plan?” information was given and discussed with the service user. There was evidence that service users meetings are held regularly, on average once a month. Minutes identified that service users are not consulted and involved in making decision about the day-to-day running of the home. Meetings appear to focus on topics such as behaviours, planners, activities, meals etc. Individual service users had posed questions to the staff with no apparent outcome or answers being given e.g. “can we go bowling?” A support worker was going to get back to service users, this evidently had not happened. Risk Assessments are incorporated within service users files, these were found to be inconsistent. One service user had clear and concise Risk Assessments in place pertinent to the individual, another service users Risk Assessments were found to be poor, with a risk-screening checklist being utilised originating from March 04. Risk levels had been amended and dated by scribbling out, their was no evidence of what work had been carried out to reduce the risks identified and what was the involvement of each service user. Paper work was scrappy with scribbling out evident. Feedback was given to the unit general manager at the end of the inspection. Evidence was gathered from viewing two care plans; discussions with care staff and service users and case tracking from other documentation within the home. Requirements have been made in these areas. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service.” Activity planners are available for each service user, however, they fail to incorporate service users choice and allow personal flexibility. Personal relationships are supported and encouraged to ensure service users maintain close links with their families and peers. Service users are encouraged to select a meal each per weekly menu, limiting control and choice about their lives. EVIDENCE: As previously stated in inspection reports each individual resident has their own weekly activity planner. It was clear in the past that individual activity planners were developed by the individual with the support from a member of staff on a week-by-week basis. However, during this inspection service users explained that the planners have recently changed from a flexible one to a more fixed planner, the same week in week out. Records confirmed that activities are on a fixed plan basis. Service users spoken with said that they Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 12 felt they couldn’t really change activities planned or incorporate adhoc activities, as there aren’t always enough staff available. It was explained that some activities do need to be worked out in advance to free up staff to accompany service users to places such as the Cinema, Bowling etc. Staff explained that service users are given the opportunity to change the planned activities the evening before depending on the staffing levels available. Records viewed identified that some staff use a reward system for service users completing their daily planner. The activity planner was found to be very prescriptive, leaving no room for manoeuvre or service users change of mind. The planners do not identify facilities accessed in the community except college for one service user. They do pinpoint specific times for out and about and one-to-one time but the actual activity is not evidenced anywhere. Service users spoken with confirmed that they preferred the old activity planners where they wrote their own activities up. Concerns were raised that activities had been identified by the staff team and then checked by service users. There was also concern that these plans are developed around the staff and not around service users. The apparent lack of reasonable flexibility and choice was discussed with the Unit General manager during the feed back meeting. Relationships are supported and encouraged by the staff team. There was evidence that service users contact family and friends regularly. Phone calls, letters and holidays with and to family regularly take place. Service users confirmed that they visit friends as identified on their planners. Service users confirmed that they have keys to their bedrooms, it was uncertain whether they also have front door keys. The staff team were observed affording service users privacy and dignity by knocking on their doors and referring to service users by their chosen preferred name. Service users spoken with confirmed that they are encouraged to select regular meals throughout the week. Breakfast and lunchtime are generally per individual as and when required. The evening meal is cooked for all three service users, occasionally one service user will assist with the preparation and cooking. Menus seen identify that service users only choose one main meal a week. Alternative meals are recorded if individuals do not like what’s being cooked. A copy of three week menus were forwarded to the Commission which identify a repetitive selection of meals that have not always been chosen by service users. There appears to be a lack of vegetables, fresh or frozen. Menus indicate that fresh fruit is available at all times. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general service users privacy is respected. The appropriate health care professionals are accessed as and when required to ensure service users receive specialist services appropriately. A few discrepancies in medication were identified potentially placing service users at risk. EVIDENCE: Service users and staff confirmed that apart from very occasionally the service users living in the home require no direct personal support. If the need does arise, it was confirmed that it would take place in the privacy of the bedrooms or the bathroom. Records confirm that all three-service users receive the appropriate health care support from the appropriate specialists as and when required. The home accesses GP’s in the community, Counsellors from the Brook Advisory centre, CPN’s, and Psychiatrists as and when required. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 14 Medication was found to be stored in the office in a locked cabinet, however the locked cabinet was not attached to the wall for safety and security. This is a requirement. Boots the chemist supplies medication where possible in blister packs. Some medication may not be stored in this format, as the tablets will breakdown. No gaps were found in the Medication Administration Records however, there was no balance being recorded appropriately on the sheets. In some cases the amount signed into the home was not available. The Disabilities Trust Medication Guidelines and in-house Protocols for Homely remedies medication were not being followed, this was reported to the unit general manager during the feedback meeting. Homely remedies must not be administered to service users unless the home has consent from the GP. As good practice a system for witnessing medication has been set up. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The organisation ensures that the appropriate policies, procedures and training are available to staff to ensure service users are protected from harm, however, concerns need to be taken more seriously to ensure service users believe that their issues are being taken seriously. EVIDENCE: No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. There is a clear and concise policy and procedure in place relating to concerns and complaints. However, there was some concern as to whether staff were treating service users concerns seriously and recording them appropriately. Through discussions with staff it was confirmed that minor issues are dealt with and not acknowledged as possibly being a serious concern/complaint. The manager needs to ensure that all staff are aware of the procedure to record all concerns received from the service users adequately and appropriately. The organisation has a Protection of Vulnerable Adults policy and procedure in place to ensure service users are safeguarded from harm. The policy adequately reflects the local authority’s interagency policy and quarterly audits are completed and forwarded to the council. A vulnerable adult issue arose during the inspection and was reported to the unit general manager for him to investigate. All staff have received the appropriate training required throughout the last 12 months. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general the environment creates a homely, comfortable and safe home for service users. EVIDENCE: Porthcawl Green is a detached house situated on an estate in Milton Keynes, close to local amenities and within easy distance of the bus routes to the centre of Milton Keynes. Communal areas consist of; on the ground floor, a lounge, a dining room, utility room and kitchen, the office is also located on this floor which has been changed since the last inspection when it was on the first floor. On the first floor there is a small quiet/visitors room, three single bedrooms, one with an en-suite, a sleep in room and the bathroom. The home is in need of some decoration to continue to offer a homely ambience. Décor is beginning to look worn, with marks and lifting paper noticeable. The bathroom paint is peeling and the floorings are unsafe, ruffling up in areas. The home was warm with adequate lighting of a domestic nature. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 17 There were no offensive odours apparent in the home and ventilation appeared to be adequate. Furnishings are all of a domestic type and appear to be of good quality. The tour of the premises communal areas confirmed that they are kept clean, tidy and free from offensive odours. Laundry facilities are that of a domestic nature suitable for the needs of service users. Incident records identified that there is a need for staff to receive training around infection control, which is a requirement. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Documentary evidence shows a low percentage of staff are adequately and appropriately trained in NVQ’s potentially failing to ensure residents are cared for by competent and qualified staff. The organisation has the appropriate systems in place to ensure that service users are safeguarded by the robust recruitment practices that are implemented. EVIDENCE: The staff team in general appear to have the competencies to meet service users needs. Overall they were observed being good listeners and communicators and seemed to have reasonable relationships with the service users. Although through observations, there was some concern in the tone and attitude of staff towards one service user. These concerns were discussed with the unit general manager during the feedback. Conversations with service users reported that they felt staff were not always pro-active in encouraging and supporting service users to access their special interests in particular in the evenings as staff do not always appear to be deployed adequately. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 19 There is a shortfall in staff achieving NVQ level 2 or above with only two staff in receipt of the certificate. Records confirm that there are seven permanent staff employed and four bank staff. The home has not reached the 50 minimum of staff being NVQ trained with a shortfall of 30 . The organisation has the appropriate systems in place to ensure that service users are safeguarded by the robust recruitment practices that are implemented. There have been no new staff since the last inspection in November 2005, however there is an increase in bank staff and the personnel records were unavailable at the time of the inspection as they had been removed to copy and maintain at the regional office. The unit general manager was asked to confirm in writing that all bank staff had clear Criminal Record Bureau Checks, references etc in place. This has not yet been received. The home has in the past improved the frequency of staff supervision and maintained appropriate records, however it was evident from the lack of records and staff confirmation that no formal supervisions have taken place since the present acting manager went on maternity leave in February. Discussion with the unit general manager confirmed that he is in the process of carrying these out. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome is poor: This judgement has been made using available evidence including a visit to this service. The home is failing to maintain its aims and objectives in the absence of the manager therefore failing to offer service users clear leadership and direction. Health and safety procedures are carried out ensuring residents are free from harm. EVIDENCE: The manager of this home has been in place for nearly twelve months and during this time has failed to submit her application for registration. A regulation 26 report received in March 06 mentioned that the manager was on maternity leave; the Commission received no official notification from the manager. The organisation carries out regular unannounced monthly proprietor visits to the home and reports are forwarded to the commission regularly. Service Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 21 users meetings take place monthly, however topics discussed appeared to be a little inappropriate; as March 06’s minutes included the discussions of individual behaviour, which should be approached in confidence. There was no evidence of consultation about the day-to-day running of the home and discussions around opinions of the overall service and how it can be improved. Where questions have been posed by the service users; there is no evidence that these have been taken seriously and followed up by the staff as there were no responses or outcomes recorded. It was not clear whether the organisation carries out its own annual quality audit by ascertaining the views of all its stakeholders. The staff have received the appropriate mandatory training required under health and safety such as Manual Handling, First Aid, Basic Food Hygiene and Fire Awareness. Professionals carry out health and safety checks annually and certificates are maintained in the home. The home’s staff recorded adequately fridge/freezer, probed food and water temperatures as required. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X 2 1 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 2 X X 3 X Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA7 Regulation 15 Requirement Timescale for action 30/06/06 2 YA9 3 YA14 4 YA20 5 6 7 8 9 YA22 YA24 YA30 YA32 YA36 To ensure that the care plans incorporate residents needs, wishes and aspirations for the future. PREVIOUS TIMESCALE OF 15/12/05 NOT MET. 13(4) The manager is required to ensure that service users have the appropriate risk assessments in place. 16(2) Ensure that service users choice (m-n) and flexibility is reflected in the activity plans by engaging in there appropriate interests. 13(2) It is required that the medication cabinet is secured to the wall and that the correct GP consent is obtained for PRN medication and homely remedies. 13(6) To ensure that the vulnerable adult issue that arose during the inspection is investigated. 23(2)(b-c) To ensure that the hall, stairs, landing and bathroom are decorated 18(1)(a) To ensure that all staff are trained in infection control. 18(1)(a) To ensure that staff are registered on NVQ training 18(2) To ensure that all staff receive DS0000030990.V290953.R01.S.doc 30/06/06 30/06/06 04/05/06 30/05/06 15/07/06 30/07/06 30/06/06 04/05/06 Page 24 Porthcawl Green (52) Version 5.1 regular formal supervision. 10 11 YA37 YA39 38 24 To ensure that the commission is notified about the management of the home. To ensure that the organisation carries out an annual quality audit. 04/05/06 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA1 YA7 YA17 YA22 Good Practice Recommendations Ensure that existing service users have access to their own copy of the Statement of Purpose and Service Users Guide. It is recommended that service users questions identified in the service users meeting minutes are responded to appropriately. It is recommended that service users are advised to seek a more balanced un-repetitive diet. To ensure that all service users concerns reported are recorded appropriately. Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Porthcawl Green (52) DS0000030990.V290953.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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